Early termination of breast-feeding in
periurban Santo Domingo, Dominican
Republic: mothers’ community perceptions
and personal practices
John D. McLennan
1Objectives. The objectives of this study were to determine: 1) whether mothers’ perceptions of typical community practice for breast-feeding duration influence their personal practices and 2) whether the mothers’ reports of community reasons for terminating breast-feeding iden-tify barriers not elicited through self-report.
Methods. The study was conducted in 1997 in a sample of poor neighborhoods in a periur-ban district of Santo Domingo, the capital of the Dominican Republic. A representative sam-ple of 220 mothers from these neighborhoods was interviewed with a structured questionnaire.
Results. While the duration of breast-feeding was similar for self-report and for mothers’ perceptions of typical community practice, there was no statistically significant correlation be-tween these two variables. “Mother-driven” reasons for early termination of breast-feeding, such as “fear of loss of figure or of breast shape” and “not wanting to breast-feed,” were frequently perceived as community reasons but rarely given as personal reasons. Personal sons were predominately “child-driven,” including “the child not wanting the breast,” or rea-sons beyond the mother’s control such as having “insufficient” milk.
Conclusions. Maternal report of community reasons for early termination may be a useful way to identify factors that would not otherwise be revealed on self-report. These additional reasons may guide health promotion efforts aimed at increasing breast-feeding duration.
Breast-feeding, surveys, research methodology, maternal and child health, Dominican Republic.
ABSTRACT
Along with many other countries in Latin America, the Dominican Re-public is reported to have a pattern of early termination of breast-feeding (1–2). This is a concern since shorter
periods of breast-feeding are associ-ated with increased morbidity and mortality in young children, particu-larly in poor communities (3–4). Multi-ple studies have identified various rea-sons for early termination; Scott and Binns (5) provide a review of the liter-ature. Nevertheless, most studies rely on maternal self-report to determine reasons for early termination of breast-feeding, or the studies restrict their analysis to various sociodemographic or behavioral variables such as the
mother’s age or the age of the child at introduction of bottle feeding. Such approaches may limit the identifica-tion of important factors that may in-fluence the duration of breast-feeding and thus limit the identification of po-tential targets for interventions.
Having the mother report on her perception of her community’s prac-tice is a complementary approach that may identify additional factors. Utiliz-ing the mother as a community infor-mant might generate a broader or dif-1 McMaster University, Canadian Centre for Studies
of Children at Risk, Hamilton, Ontario, Canada. Send correspondence to: John McLennan, Cana-dian Centre for Studies of Children at Risk, Mc-Master University, Patterson Building, 2nd Floor, 1200 Main Street W., Hamilton, Ontario, Canada L8N-3Z5. Telephone: (905) 521-2100, ext. 74176; fax: (905) 574-6665; e-mail: [email protected]
ferent range of responses than might be the case if a mother only reported on her own experience. Such question-ing would allow the mother’s response to be based on all her experiences with other women in the community. Such questioning may also identify reasons that are less socially acceptable and hence less likely to be elicited on self-report.
A second reason for this research approach would be to investigate whether perceptions of community practice influence a mother’s own practice. According to Ajzen’s theory of planned behavior (6), such influence could occur through an impact on “normative beliefs” (the perceived be-havioral expectations of others); those beliefs in turn contribute to “subjective norms” (the perceived social pressure to engage in behavior). For some be-haviors, such as adolescent substance abuse, the perception of others’ prac-tices has been found to be a more pow-erful predictor of personal use than actual community practice (7). How-ever, whether perception of commu-nity practices on breast-feeding is asso-ciated with actual practice is unknown.
This study utilized data from a com-munity study to determine the dura-tion of breast-feeding and the reasons behind early termination, as reported by mothers about their personal experi-ence and about their perception of their community’s practice. It was hypothe-sized that duration of breast-feeding would be influenced by perception of the community’s practice and that ma-ternal reports on others would reveal additional reasons for early termina-tion of breast-feeding not available through self-report alone.
MATERIALS AND METHODS Setting
The study site was Los Alcarrizos, a predominantly poor periurban district of Santo Domingo, the capital of the Dominican Republic. Six poor barrios (neighborhoods) were chosen from this district. These barrios were chosen for two reasons: 1) a local child
malnu-trition clinic frequently receives refer-rals from these neighborhoods and 2) local health promotion groups have chosen these barrios for health educa-tion interveneduca-tions. Choosing neighbor-hoods targeted for intervention in-creases the possibility that the study could have input into health education efforts. These barrios were fairly new communities, having been established between 2 and 10 years before the time of the study, which was carried out in 1997. The neighborhoods had been set-tled predominantly by squatters.
Sample
In each of the chosen neighborhoods, every tenth house along each road and path was visited. If a child 5 years of age or younger lived in the home and a primary caretaker of that child was available, that caretaker was invited to participate in the study interview. The interview covered a variety of topics related to diarrhea prevention and hy-giene, with breast-feeding questions interspersed throughout the interview schedule.
If a primary caretaker was not ini-tially available or there was no one home, the house was visited up to two further times in an attempt to obtain an interview. This sampling process resulted in visits to 353 houses. Of these, 82 did not have any children under the age of 5 years, and 3 houses were visited repeatedly but no one was encountered. Of the remaining 268 households that were eligible for the interview, 2 declined to partici-pate, leaving 266 households (99.3% of the total eligible) that completed the interview. If the mother in the house-hold had more than one child 5 years of age or younger there in the home, one child was randomly identified as the “index” child for the personal breast-feeding questions asked in the interview.
From these 266 participating house-holds, in 220 of them (82.7%) the per-son completing the interview was the mother of the index child. We re-stricted the breast-feeding analyses to this group of women. The caretaker
non-mothers who were interviewed but excluded from our breast-feeding analyses were primarily grandmoth-ers. Information on the full set of re-spondents—mothers and non-moth-ers—has been previously reported, along with data on other health prac-tices covered in the interview, includ-ing the caregivers’ use of purified drinking water with their children (8).
Procedure
The entire study was approved by the staff at the Children’s Project/ Health Center Clinic in Los Alcarrizos and by the Institutional Review Board committee at the University of Pitts-burgh. Written informed consent was obtained from all participants. All questions were asked and recorded in the child’s home by two Dominican fe-male research assistants who had pre-vious community health and survey interview experience as well as some university education.
Breast-feeding interview questions
breast-feeding termination, mothers were first given an opportunity to pro-vide as many spontaneous reasons as they wished and were then asked if there were any other reasons until they provided no further responses.
Analysis
Data analyses included Spearman correlation, chi-square (2) analysis with continuity correction, and paired t test. The analyses were performed using SAS System version 6.12 soft-ware (SAS Institute, Cary, North Car-olina, United States of America).
RESULTS
The 220 mothers who completed the interviews had a mean age of 26.4 years (standard deviation (SD), 6.7 years) and 6.1 years of education (SD, 3.7 years). They had a mean of 3.5 children (SD, 2.3 children), with the index child having a mean age of 27.9 months (SD, 18.5 months). Ninety-seven percent of mothers indicated that they initiated breast-feeding when the index child was a baby. Twenty-three percent of the mothers (51 of them) were still breast-feeding the index child at the time of the interview.
All the mothers reported on their du-ration of breast-feeding with the index child, if they had terminated breast-feeding with that child. However, only 181 of the 220 mothers (82.3%) pro-vided a response to the question on du-ration of typical community practice. Nonresponse to this question appeared to be a function of some mothers being reluctant to guess at a value for the community. Table 1 shows the results for the personal duration and for the mothers’ perception of typical commu-nity duration practice.
The values are similar for self-report and for perception of community prac-tice (Table 1). Despite there being sim-ilar values in these two categories, the Spearman correlation analysis showed no relationship between personal du-ration of breast-feeding and perceived community duration for the 137 women
who had terminated breast-feeding and who also responded to the com-munity duration question (Spearman correlation r= –0.06, P= 0.490). There was also no relationship found when the values were dichotomized to less than 12 months versus 12 months and greater (2= 1.36, P= 0.243).
Both categories had very large modes at 12 months (41 women for personal duration; 84 women for per-ception of community duration). These modal frequencies may be inflated given a likely pattern of rounding to the nearest year by some mothers. Not captured in Table 1 is that 26% of those no longer breast-feeding had termi-nated before the child reached 3 months of age. This is in contrast to only 7.7% perceiving the community value to be 3 months or less.
The most common reasons that mothers gave for themselves person-ally terminating breast-feeding were that the “child did not want it,” that the mother was pregnant with her next child, and she had “no” or “insuffi-cient” milk (Table 2). Similar results were found for the subgroup that had breast-fed for less than 1 year, except that pregnancy was a much less com-mon reason.
In terms of perceptions of commu-nity reasons for terminating breast-feeding before 1 year, the most com-mon reason given was “no” or “insufficient” milk (Table 2), which was also a personal reason that many mothers reported for themselves. In contrast, the next most common
rea-sons perceived for the community were not so highly rated as personal reasons. These included the mother being concerned about “loss of her fig-ure” or “loss of breast shape” (pérdida de la figura or caída de los senos), the mother “not eating well,” the mother “not wanting to,” and the mother “having to work.” A similar distribu-tion of community reasons was found when just considering the subsample of early terminators, that is, those ter-minating breast-feeding before the child reached 1 year of age.
DISCUSSION
In terms of duration of breast-feed-ing, the values found were similar for the mothers’ self-report and for their perception of community prac-tice. Despite this similarity, this study found no statistical correlation be-tween these two values. Nevertheless, in looking at reasons behind early ter-mination of breast-feeding, the study did find that having the mothers pro-vide their perceptions of community practice generated important addi-tional data concerning barriers to pro-longed breast-feeding that were not re-vealed through self-report alone.
The lack of relationship between perceived community practice and personal practice is consistent with re-sults of research on the duration of use of purified drinking water for chil-dren in this same study (8). The age at which drinking water was no longer TABLE 1. Duration of breast-feeding according to mothers’ personal reports on themselves and their perception of community practices, Dominican Republic, 1997a
Standard
Meanb deviation Median Mode Range
(mo) (mo) (mo) (mo) (mo)
Personal duration 10.2 8.2 8 12 0–36
Perceived duration of
typical community practice 11.5 6.6 12 12 0–24
aInformation on personal duration is from 169 mothers who had terminated breast-feeding prior to the study; information on perceived duration of typical community practice is based on replies from the 181 of the 220 of the participants (82.3%) who responded to this question.
purified for the index child was not as-sociated with the caretakers’ percep-tion of community practice.
Nevertheless, further investigation of perceptions of community practice on breast-feeding may be warranted. First, it might be useful to look at the impact of the perceived practice of dif-ferent persons within the mothers’ so-cial networks (10). Perhaps duration of breast-feeding practiced by close fam-ily members or friends would have a greater likelihood of influencing moth-ers’ practices than would perceived com-munity practice. Secondly, it might be useful to look at the expectation of oth-ers as opposed to the perceived prac-tice of others in order to better tap the concept of “subjective norms” (6).
The self-report reasons for termi-nation of breast-feeding in this study are consistent with common reasons found in a previous study in this same district (11) and in studies of other populations (12–14). In contrast, some of the perceived community reasons in this study have been much less quently reported. In addition, the
fre-quency of different reasons is very dis-crepant between self-report and com-munity perception in this study.
The concern over the loss of one’s figure or breast shape was one of the most discrepant findings in this study. This reason has previously been pro-posed as a factor that may influence the initiation of breast-feeding (10, 5–17). However, the reason does not appear to have been reported in the lit-erature as a possible factor influencing the duration of breast-feeding. This is in spite of the fact that it is a familiar issue for those working in the field. Also not evident in the literature is the actual impact of breast-feeding on breast shape. Breast-feeding is not listed as a common cause of breast pto-sis (18); rather, breast ptopto-sis may pri-marily be a function of the effects of pregnancy (19).
In cases where the termination-reason frequency was high for community per-ception but low for personal report, such discrepancies were often for termi-nation reasons that might be considered less socially acceptable, especially in an
environment where breast-feeding is heavily promoted as being critical for healthy child development. Perhaps the implication is that mothers ought to have a “good reason” not to provide prolonged breast-feeding since they are placing their children at risk by early ter-mination. It has been reported that some mothers may feel pressure or a sense of guilt when deciding not to breast-feed (20–21). In such an environment, it may be less acceptable for mothers to make decisions based on personal reasons (e.g., “concern about figure,” “not want-ing to breast-feed”) than on “child-driven” reasons (e.g., “he/she no longer wanted the breast”) or on barriers be-yond a mother’s control such as having “insufficient” milk. Consistent with this pattern is that one of the most highly discrepant findings in the other direc-tion—that is, with the reasons given much more frequently as a personal one than as a community-perceived one— was the “child did not want the breast.” The high frequency of this “child-driven” reason may be partially a func-tion of its social acceptability.
TABLE 2. Reasons for breast-feeding termination according to mothers’ personal reports on themselves and their per-ception of community practices, Dominican Republic, 1997a
Personal reason Perceived community reason
All Breast-fed Full Breast-fed
terminatorsb < 1 yearc sampled < 1 yearc (163 mothers) (87 mothers) (206 mothers) (86 mothers)
Reason No. % No. % No. % No. %
Child did not want it 53 32.5 42 48.3 19 9.2 9 10.5
Pregnancy 28 17.2 7 8.0 15 7.3 6 7.0
No or insufficient milk 23 14.1 20 23.0 77 37.4 37 43.0
Needed weaning 21 12.9 2 2.3 7 3.4 4 4.7
Separated from child 21 12.9 10 11.5 59 28.6 29 33.7
Mother sick 9 5.5 6 6.9 14 6.8 10 11.6
Mother working 8 4.9 3 3.4 46 22.3 18 20.9
Other 4 2.5 1 1.1 4 1.9 2 2.3
Damage to the mother 14 8.6 3 3.4 20 9.7 8 9.3
Mother didn’t want to
breast-feed 4 2.5 1 1.1 50 24.3 21 24.4
Concerned about loss of figure
or breast shape 0 0.0 0 0.0 69 33.5 25 29.1
Mother not eating well 0 0.0 0 0.0 53 25.7 24 27.9
Miscellaneous 9 5.5 6 6.9 33 16.0 11 12.8
aMothers could give more than one answer; total samples vary slightly due to some missing data. bAll terminators = those who terminated breast-feeding prior to the interview.
The reported frequency of the “mother working outside of the home” as a reason for early termina-tion of breast-feeding was also dis-crepant between the community and personal report. However, this may be partially explained by the sampling procedure, which would have missed some working mothers. Support for this as a factor for influencing the dis-crepancy was found in the response pattern of the non-mother caretakers interviewed for those mothers who were not available for the study inter-view. Twenty percent of the 45 non-mothers believed that work was a per-sonal reason for mothers’ termination of breast-feeding. This value is close to the 22.3% of mothers reporting this as a perceived community reason (Table 2). This may grow as an important personal and community-perception reason given that “free trade zone” factories are located close to these communities and that young women
form a substantial fraction of the labor force for such factories.
How might these results inform in-terventions aimed at improving breast-feeding duration? First, there is a need to consider the most common re-sponses for breast-feeding termination, i.e., “no or insufficient milk” for the community reason and “child not wanting it” for the personal reason. Unfortunately, factors contributing to these problems were not explored fur-ther in this study. Factors may include faulty positioning or technique, inac-curate perceptions about adequacy of breast milk, and impact of early sup-plementary feeding. If these factors turn out to be significant contributors to shortened breast-feeding duration, then education and support programs could be directed towards them.
Second, there may be a need to ad-dress the frequent report of “mother-based” reasons for early termination. Certainly, further study is warranted
to better determine the extent of influ-ence of these reasons. One possibility would be to modify health promotion messages to stress breast-feeding ben-efits for the mother (22).
Finally, other interventions may need to be considered to address less fre-quently reported difficulties. In order to decrease the negative impact of in-creased work demands on mothers out-side of the home, it may be necessary to increase the opportunities for breast-feeding in the workplace. In addition, improved availability of family plan-ning services may be required in order to decrease the role of pregnancy in the early termination of breast-feeding.
Acknowledgements. This study
was funded through a faculty research grant from the Center for Latin Amer-ican Studies, University of Pittsburgh, Pittsburgh, Pennsylvania, United States of America.
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Manuscript received 31 January 2001. Revised version ac-cepted for publication on 4 May 2001.
Objetivos. Los objetivos de este estudio consistieron en determinar: 1) si las percep-ciones de las madres acerca de las prácticas de lactancia materna típicas de su comu-nidad influyen sobre sus prácticas personales, y 2) si las respuestas de las madres sobre los motivos que llevan a interrumpir la lactancia materna en su comunidad identifican problemas no reflejados en las respuestas sobre sus propias prácticas.
Métodos. El estudio se realizó en 1997 en una muestra de barrios pobres de un
dis-trito periurbano de Santo Domingo, la capital de la República Dominicana. Se utilizó un cuestionario estructurado para entrevistar a una muestra representativa de estos barrios, formada por 220 madres.
Resultados. Aunque la duración de la lactancia materna fue similar en las
respues-tas sobre las prácticas personales y sobre las prácticas de la comunidad, esrespues-tas dos vari-ables no estaban correlacionadas entre sí de forma estadísticamente significativa. Las razones “relacionadas con la madre” para interrumpir precozmente la lactancia, tales como el “temor a perder la figura o a la caída de los senos” y el “no querer dar de mamar”, aparecieron frecuentemente como motivos en la comunidad, pero no como motivos personales. Los motivos personales fueron principalmente los “relacionados con el niño”, como “el niño no quiere el pecho”, o razones fuera del control de la madre, como el tener “insuficiente” leche.
Conclusiones. Los motivos identificados por la madre como causas de interrupción
precoz de la lactancia materna en su comunidad pueden constituir una forma útil de identificar factores que habitualmente no se revelan en los cuestionarios sobre las prácticas personales. Estos motivos adicionales pueden ser útiles para guiar los es-fuerzos de promoción de la salud destinados a aumentar la duración de la lactancia materna.
RESUMEN
Interrupción precoz de la
lactancia materna en la zona
periurbana de Santo Domingo,
República Dominicana: las
prácticas personales de la
madre y su percepción de las
prácticas de la comunidad
Reunión satélite sobre la biología básica de las tricomonas
Fecha: 3 a 6 de noviembre de 2001 Lugar: Rio de Janeiro, Brasil
En el contexto de la XVII Reunión Anual de la Sociedad Brasileña de Protozoología y de la VIII Reunión Anual de Investigaciones Básicas sobre la Enfermedad de Chagas, se celebrará una reunión satélite sobre la biología básica de las tricomonas (Trichomonas vaginalis y Trichomonas foetus) y otros parásitos protozoarios anaerobios y aerobios, principalmente Entamoeba histolytica y Giardia lamblia.
Información:
Fernando Costa e Silva Filho, Ph.D. UFRJ-Instituto de Biofísica Carlos Chagas Filho
CCS-Bloco G, Ilha do Fundão 21949-900, Rio de Janeiro, Brasil
Tel.: 55-21-562.6569 (lab) Fax: 55-21-280.8193 Correo electrónico: [email protected]
o
John F. Alderete, Ph.D. Department of Microbiology University of Texas Health Sciences Center
San Antonio, Texas U.S.A.
